HomeMy WebLinkAbout2024-00068162 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets II III IIIOII III I
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ®$501-$1,500 ®ON SCENE 2
El NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2O24I2O24-00068162 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH '17
LILLIAN ST ® ❑
Elgin RELATED ❑Y coN 10 25 2024 05:00 ❑AM ❑YES ®No u1 ,<
PRIVATE mo /day I yr ®PM FLOW CONDITION m
EP (EjI MI N E s® South Clifton
) PEDALCYCUST® ® FREE FLOW # LNS 0
❑DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL ❑ECUES 0 rev 0 ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGED AREA(S) FRONT_ TOWED U1 0
00-NONE 11 12 1 DUE TO CRASH El El
NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 1 2 FIRE ❑ 0
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)
SYSTEM IN ENGAGED 15-OTHER DISTRACTED 0 0 U2 m
9 76-TOP 3
r ❑Y ❑N ❑UNK VEH. AT CRASH POINT UNKNOWN
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m / / FOR DAMAGED AREA(S) FRONT TOWED
fi 1 DUE TO CRASH 0 0
, NAME(LAST,FIRST,M) mo day yr 00-NONE 11. 12 73
a 13-UNDER CARRIAGE 101 -. 2 FIRE ❑ 0 U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 SPDR 0
a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 X
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 'Distraction Value U1
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DYOIDN Ut I
(UNIT) (SEAT) (DOB) ISEXI ISAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) C)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z
N 1 El 10/25 /2024 05 00 0 pm in a Work Zone? ®N DIRP co
PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 0 T 2 ❑
co / / 0 PM ❑Construction *
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cs 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEi AM El Maintenance U2
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ARREST NAME / / ❑PM SLMT
,- u 1 0 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility
o N AM
2 ❑ ARREST NAME 10/25 /2024 05 10 lilPM 0 Unknown work zone type U1
Fo T OFFICER ID SIGNATURE BEAT/DIST. •
SUPERVISOR ID. COURT DATE TIME
2 3 ID _ ❑AM Workers present? El
1528-Rivera. Kevin 701 11 1 26/2024 01 30 0 PM ®N U2
REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS!
A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE
even if units have been moved prior to officer's arrival.
r IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
• ADDITIONAL UNITS FORMS
' } A CMV is defined as any motor vehicle used to transport passengers or property and
, . r r r r , , , , . r0 .
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1 Has a weight rating more than 10,000 pounds(example.truck or truck/trailer
r 'I 1 ; i i i f i- r r , , i INDICATE NORTH combination)or —I
X
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I ', ! ' ' 1 ', ' f ` r r r (example'.shuttle or charter bus)-or 0
; ; I ; I I ;
3 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i_-----'-----a a a I t • : - -, I a + i } - t transporting employees in the course of their employment(example.employee 71
transporter-usually a van type vehicle or passenger car).or 03
' i i 4 Is used or designated to transport between 9 and 15 passengers,including the driver
r 9 Po P 9 N
for direct compensation(example:large van used for specific purpose).or O
i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example placards will be displayed on the vehicle) M
•
CARRIER NAME Z
' .. ADDRESS
N
• CITY/STATE/ZIP 0
^ MOTOR CARR ID ❑ Interstate ❑ Intrastate <
• . ❑ Not in Comm./Govt. ElNot in Comm./Other 0
r---- ----, , , r r r r r----, , , , r USDOT NO ILCC NO. m
•• , • Source of above z
_
WereHAZMAT placards on vehicle? ❑ Yes ❑ No —I
If Yes, Name on placard 0
4 digit UN NO. 1 digit Hazard class No X
X
m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicles z
own tank)? ❑ Yes ❑ No ❑ Unknowr D
Did HAZMAT Regulations violation contnbute to the crash? r
❑ Yes ❑ No ❑ Unknown
D
Did Carrier Safety Regulations(MCS)violation contribute to the crash% p
❑ Yes No ❑ Unknown C
Was a driver/vehicle Examination Report Form completed? 1.
HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ No -
MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No C
z
Form Number 0
_ m
— X
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2
TRAILER VIN 1 _ m
to
LOCAL USE ONLY TRAILER VIN 2 m
TRAILER WIDTH(S) 0-96'1 97-102'1 >10? m
TRAILER 1 ❑ ❑ ❑ z
-71
TRAILER 2 ❑ ❑ ❑ 3
U COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't z
• TOTAL VEHICLE LENGTH ft. NO.OF AXLES
U TOWED ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- TOWED BY/TO
DUE TO SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- TOWED BY/TO:
DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE